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@@ -46,8 +46,6 @@
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<div class="alert alert-success" role="alert">
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<h4 class="alert-heading">Congratulations!!</h4>
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<p>You have successfully completed this survey. Eligible submissions will receive a digital gift cards in 7 business days to the email provided in the survey. </p>
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- <hr>
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- <p class="mb-0">Questions? please feel free to write us at <a href="mailto:info@hemband.com">info@hemband.com</a> or call us at <a href="tel:(800) 242-6145">(800) 242-6145</a></p>
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</div>
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</div>
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@else
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@@ -73,31 +71,31 @@
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</div>
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<div class="col-md-6 mb-3">
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<div class="form-group">
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- <label>Cell Number</label>
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- <input type="text" class="form-control" name="cell_number" value="{{ old('cell_number') }}" />
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+ <label>Mobile Number</label>
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+ <input type="text" class="form-control phone" name="mobile_number" value="{{ old('mobile_number') }}" />
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</div>
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</div>
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</div>
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<div class="row">
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<div class="col-md-6 mb-3">
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<div class="form-group ">
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- <label>Practice Address Line 1</label>
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+ <label>Practice Address</label>
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<input type="text" class="form-control" name="practice_address_line_1" value="{{ old('practice_address_line_1') }}" />
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</div>
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</div>
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<div class="col-md-6 mb-3">
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<div class="form-group ">
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- <label>Practice Address Line 2</label>
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+ <label>Practice Address Street</label>
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<input type="text" class="form-control" name="practice_address_line_2" value="{{ old('practice_address_line_2') }}" />
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</div>
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</div>
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- <div class="col-md-6 mb-3">
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+ <div class="col-md-4 mb-3">
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<div class="form-group ">
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<label>Practice Address City</label>
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<input type="text" class="form-control" name="practice_address_city" value="{{ old('practice_address_city') }}" />
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</div>
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</div>
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- <div class="col-md-6 mb-3">
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+ <div class="col-md-4 mb-3">
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<div class="form-group">
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<label>Practice Address State</label>
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<select class="form-control" name="practice_address_state">
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@@ -108,6 +106,12 @@
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</select>
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</div>
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</div>
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+ <div class="col-md-4 mb-3">
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+ <div class="form-group ">
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+ <label>Practice Address Zip Code</label>
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+ <input type="text" class="form-control zip" name="practice_address_zip_code" value="{{ old('practice_address_zip_code') }}" />
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+ </div>
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+ </div>
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</div>
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</div>
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</div>
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@@ -131,7 +135,7 @@
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<div class="row mb-3">
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<div class="col-12 question">
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<div class="form-group">
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- <label>Years in practice</label>
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+ <label>Years in the practice</label>
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<div id="rangeSlider" class="noUiSlider"></div>
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<input type="hidden" name="years_in_practice" :value="form.years_in_practice" />
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</div>
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@@ -305,17 +309,17 @@
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noUiSlider.create(slider, {
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start: 0,
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+ step: 5,
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connect: 'lower',
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range: {
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'min': 0,
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'max': 70
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},
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- step: 1,
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tooltips: true,
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format: format,
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pips: {
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mode: 'steps',
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- format: format
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+ format: format,
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},
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});
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slider.noUiSlider.on('update', function(values, handle) {
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